*Please feel free to download and/or use this video as a teaching tool.

Annie's story is an example of how healthcare organizations seeking high reliability embrace a just culture in all they do. This includes a system's approach to analyzing near misses and harm events—looking to analyze events without the knee-jerk blame and shame approach of old. Learn more about Quality and Patient Safety (http://ow.ly/M1aZk) and Human Factors Engineering in Healthcare (http://MedicalHumanFactors.net).

In the short five minutes we had to tell Annie's story, we chose to focus on the main theme—the human cost to our healthcare workforce when we fail to cultivate a just culture and systems approach overall, but especially when managing unfortunate harm events. As we had hoped, this story has inspired conversation, and we are grateful for that conversation. When patient harm occurs, caregivers involved are devastated along with the patient and family, yet for far too long many have had to navigate this storm alone. It is up to us as healthcare providers to demand that a systems approach be a given in our healthcare workplace, along with the just culture that cultivates the sharing of knowledge and helps prevent patient harm from occurring altogether.

Please keep in mind this could have happened to any nurse or healthcare provider in any hospital using any equipment, process or tool. If we fail to analyze the entire system before placing blame on any one individual when things don't go as planned, we will unfortunately continue to harm patients and care providers at the same untenable rate as we have since called to light in 1999. This event provided an opportunity to improve a process across ten hospitals because of the willingness of healthcare providers involved to ask for help analyzing a threat to the system, and because leadership followed their instincts—that good healthcare providers should not be punished for system failures. Thanks for watching—please share and continue the conversation.